Oncology

Alkylating medications
th
• Adds an alkyl group to the 7 nitrogen on Guanine
• Form cross-bridges, preventing cancer DNA from replicating
• Acts on all phases in cell cycle – mostly S phase
• Examples:
o Cyclophosphamide – nitrogen mustard
▪ Metabolised by the liver
▪ Used for: leukaemias, lymphomas, ovarian & breast cancers
▪ Side effects: aplastic anaemia,
leukaemia, hair loss, infertility,
GI disturbances, SIADH
o Ifosfamide – nitrogen mustard

▪ More toxic than

cyclophosphamide
▪ Metabolised by the liver
▪ Used for: leukaemias, lymphomas, ovarian & breast cancers, sarcomas
▪ Side effects: hair loss, haemorrhagic cystitis, aplastic anaemia, leukaemia,
infertility, GI disturbances, SIADH
▪ Co-administration of thiol mesna can lessen side effects
o Carmustine/lomustine – nitrosureas

▪ Can cross the blood-brain barrier

▪ Used for: glioblastoma multiforme
▪ Side effects: neurotoxic
o Cisplatin – platinum alkylating-like

▪ Very toxic
▪ Radio-sensitising
▪ Used for: testicular, bladder, lung, ovarian & cervical cancers
▪ Side effects: nephrotoxicity, peripheral neuropathy, ototoxicity, GI
 disturbances
o Carboplatin – platinum alkylating-
like
▪ Less toxic than cisplatin,
preferred in all cases except
germ cell tumours
▪ Radio-sensitising
▪ Used for: testicular, bladder, lung, ovarian & cervical cancers
▪ Side effects: severe bone marrow suppression – worse at day 14
o Oxaliplatin – platinum alkylating-like

▪ Radio-sensitising
▪ Used for: advanced colon cancer, carcinomas, lymphomas
▪ Side effects: peripheral neuropathy, GI disturbances, nephrotoxicity,
ototoxicity, bone marrow suppression – less than cisplatin & carboplatin

Anti-tumour antibiotics
• Examples:
o Doxorubicin – anthracycline
▪ Acts on all phases in cell cycle – mostly S phase
▪ IV route
▪ DNA interference
▪ Generates free oxygen radicals
▪ Used for: breast, thyroid, lung & ovarian cancers, leukaemias & lymphomas
▪ Side effects: dilated
cardiomyopathy (prevented
by dexrazoxane),
myelosuppression, alopecia
o Daunorubicin – anthracycline

▪ Acts on all phases in cell cycle –

mostly S phase
▪ Oral route
▪ DNA interference
▪ Generates free oxygen radicals
▪ Used for: breast, thyroid, lung & ovarian cancers, leukaemias & lymphomas
▪ Side effects: dilated cardiomyopathy (prevented by dexrazoxane),
myelosuppression, alopecia
o Bleomycin – miscellaneous
 ▪ Mostly effective in the G phase
2

▪ Generates free oxygen radicals

▪ Used for: Hodgkin’s lymphoma, testicular cancer, squamous cell carcinoma of
the skin
▪ Side effects: pulmonary toxicity, rash, hyperpigmentation, mucous membrane
toxicity, alopecia, minimal myelosuppression
o Mitomycin – miscellaneous

▪ Used as a radio-sensitiser

Topoisomerase inhibitors
• Acts on S phase
o Topotecan – camptothecan
▪ Topoisomerase I inhibitor
▪ Eliminated through kidneys
▪ Used for: advanced ovarian
cancer & SCLC
▪ Side effects: severe diarrhoea,
myelosuppression
o Etoposide – podophyllotoxin

▪ Topoisomerase II inhibitor
▪ Eliminated through kidneys
▪ Used for: testicular cancer, SCLC, leukaemias, lymphomas
▪ Side effects: myelosuppression, emesis, alopecia

Anti-metabolites
• Acts on S phase
• Examples:
o Methotrexate – folate antagonist
▪ Inhibits dihydrofolate reductase (DHFR) therefore reducing purine synthesis
▪ Used for: leukaemias, lymphomas, breast, head & neck & bladder cancers
▪ Side effects: myelosuppression (reversed with leucovorin), megaloblastic
anaemia, liver toxicity, pulmonary fibrosis, alopecia, mucositis
o 5-Fluorouracil – pyrimidine antagonist

▪ Metabolises to 5-FdUMP – active ingredient

▪ Inhibits thymidylate synthase (TS)
 ▪ IV route
▪ Uridine is an antidote
▪ Used for: GI cancers, colorectal, pancreatic, head & neck, breast, ovarian,
bladder & HCC
▪ Side effects: hand & foot syndrome, severe diarrhoea
o Capecitabine – pyrimidine antagonist

▪
▪ Oral route
▪ Metabolised by the liver
▪ Used for: GI cancers,
▪ Side effects: liver toxicity, severe diarrhoea
o Gemcitabine – pyrimidine antagonist

▪ IV route
▪ Used for: pancreatic, NSCLC, ovarian, bladder cancers & non-Hodgkin’s
lymphoma
▪ Side effects: myelosuppression, pulmonitis, liver toxicity
o Pemetrexed – purine antagonist

▪ Inhibits TS & DHFR

Microtubule inhibitors
• Acts on M phase
• Overstablises the microtubules and prevents them from depolymerising and breaking down,
preventing anaphase from happening
• IV route
• Examples:
o Paclitaxel – taxane
▪ Used for: breast, ovarian, lung,
gastroesophageal, prostate,
bladder, head & neck cancers
▪ Side effects: neuropathy,
alopecia, myelosuppression
o Docetaxel – taxane

▪ Used for: breast, ovarian, lung, gastroesophageal, prostate, bladder, head &
neck cancers
▪ Side effects: neuropathy, alopecia, myelosuppression
Monoclonal antibodies
• Extracellular binding to specific overexpressed antigens
• Examples:
o Bevacizumab – humanised
▪ VEGF inhibitor
▪ Used for: colon & renal cancer
▪ Side effects: impaired wound
healing, haemorrhages,
epistaxis, haemoptysis
o Trastuzumab – humanised

▪ HER2 inhibitor
▪ Used for: breast cancer
▪ Side effects: cardiotoxicity, GI symptoms
o Cetuximab – chimeric

▪ EGFR inhibitor
▪ Radiosensitiser
▪ Used for: metastatic colorectal cancer, head & neck cancers
▪ Side effects: hypersensitivity, GI symptoms

Tyrosine kinase inhibitors – targeted agents

• Intracellular binding
• Examples:
o Erlotinib
▪ EGFR inhibitor
▪ Used for: NSCLC
o Imatinib
o Lapatinib
▪ HER2 inhibitor
▪ Used for: breast cancer

Head & neck cancer

Pathophysiology
• Squamous cell carcinomas
Risk factors
 • Smoking
• Alcohol
• Diet
o Deficient in Vit A & C
o Nitrosamines in salted fish
o Smoked foods
• Infections
o HPV
▪ Laryngeal, pharyngeal, tonsil, oral
o EBV
▪ Nasopharyngeal
• Precancerous lesions
o Leukoplakia
o Erythroplakia
• Genetics
o Mutations in p53 (oral cancer)
• Formaldehyde
• Radiation exposure
• Fanconi anaemia
Symptoms
• Laryngeal cancer
o Hoarse voice
o Irritating cough
o Dysphagia/odynophagia
o Palpable neck mass
o Referred ear pain
o Haemoptysis
• Oral cancer
o Persistent mouth ulcers
o Painful ulcerative lesion on the lip
o Exophytic growth >3 weeks
o Numbness
o Dysphagia
 o Lymphadenopathy
• Pharyngeal cancer
o Dysphagia
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
o CT – to determine staging
o MRI
o FDG-PET-CT
▪ Gold standard for staging
• Biopsy (excisional)
o Most commonly squamous cell carcinoma
o Invade adjacent structures & lymph nodes
Differential diagnosis
•
Staging
• Laryngoscopy + FNA
Treatment
• Stage I, II
o Conservative surgery or radiotherapy
(external or brachytherapy)
• Stage III, IV resectable
o Surgery w/ adjuvant chemotherapy
o Chemoradiation therapy
(cetuximab/cisplatin + radiotherapy)
o Neoadjuvant chemotherapy (taxane +
platinum + 5FU) + radiotherapy/surgery
• Stage IV unresectable
o Targeted drug (cetuximab)
o Immunotherapy (pembrolizumab) – when PDL > 50%
o Chemotherapy (TPF)
• Recurrence
 o For recurrence, never used the same method used originally. If radiotherapy was
used initially, next use chemotherapy
o Cetuximab + cisplatin / carboplatin + 5FU (for fit patients)
o Weekly methotrexate (poor tolerance)
• Follow-up
o Imaging every 3 months (after 1 year); every 6 months (after 2 years); every year
(after 4 years)
o Physical exam
o TSH – if neck radiation occurs (hypothyroidism is common)
• Complications
o Odynophagia
o Dysphagia
o Permanent lost voice
Prognosis
• 5-year survival for stage I = 80%
• Salivary gland tumours have the worst prognosis (most common location is the parotid gland)
Special notes
• Oral cancer is most common head & neck cancer
nd
• Laryngeal cancer is 2 most common head & neck cancer. Most prominent in males
• Smoking + alcohol is synergistic. Will increase the chance of getting caner if both are done
• Viral induced cancers have a better prognosis
• Fanconi anaemia patients have an elevated risk of head & neck cancer. With greater toxicity
with cisplatin chemo- & radiotherapy

Lung cancer
Pathophysiology
• NSCLC – originates from epithelial cells of the lung
o Adenocarcinoma – peripheral
o Squamous cell carcinoma – central
o Large cell carcinoma
• SCLC – originates from nerve producing cells of the lung and neuroendocrine tissues
o Classical small cell lung carcinoma – central
o Large cell neuroendocrine tumour
o SCLC + NSCLC
Risk factors
• Smoking
o Not for adenocarcinoma
• FHx
• Radiation exposure
• Environmental exposures i.e., asbestos, pollution, radon
• p53/RB1/p16 mutation – SCLC
Symptoms
• Usually asymptomatic
• Incidental single pulmonary nodule – NSCLC
• Cough
• Haemoptysis
• SOB
• Weight loss
• Finger clubbing
• Stridor
• Frothy sputum production
• Hoarseness
• Horner’s syndrome
• Superior vena cava syndrome
• Metastatic involvement
o Bone pain
o Hypochondrial pain
o Altered mental status
o Paraneoplastic syndromes – SCLC
▪ Eaton-Lambert syndrome
▪ Ectopic ACTH
▪ Hypercalcaemia
Diagnosis
• Medical hx
• Physical exam
• CBC
• CT chest
 • Brain MRI
o For SCLC / stage III NSCLC
• Bronchoscopy
• FNA
o To make sure it is lung cancer
o To find out if it is SCLC/NSCLC
• PET-CT
o For staging
Differential diagnosis
• Pneumonia, atelectasis, ARDS, Cushing’s, SIADH
Staging
• T1 – < 3 cm
• T2 – 3-5cm
• T3 – 5-7cm
• T4 – > 7cm
• N – lymph node involvement
• M – distant metastasis
Treatment
• NSCLC
o Stage I, II, IIIa
▪ Surgery (largest resection is a lobectomy, never pulmonectomy)
▪ + Adjuvant chemotherapy (carboplatin + paclitaxel)
o Stage IIIb
▪ Paclitaxel + carboplatin / gemcitabine + cisplatin
▪ + Radiation therapy
o Stage IV – if targets are +ve
▪ EGFR (erlotinib)/KRAS/ALK (crizotinib)/ROS/RET/MET
o If targets are -ve
▪ + PDL > 1%
• Chemotherapy + pembrolizumab
▪ + PDL > 50%
• Pembrolizumab only
o Stage IV or recurrent disease w/no targets + no PDL (palliative care)
 ▪ Chemotherapy (carboplatin + paclitaxel)
▪ Radiation therapy (for brain metastasis)
• SCLC – palliative
o Chemoradiation therapy – limited stage (confined to lungs)
▪ Cisplatin + etoposide + radiation therapy
o Chemotherapy – extensive stage
▪ Cisplatin + etoposide + azetolizumab
• Complications:
Prognosis
• NSCLC – poor prognosis, but favourable for females, normal LDH, stage I
• SCLC – poor prognosis, but favourable for normal LDH, 1 metastatic site
Special notes
nd
• 2 most common cancer in the world
• SCLC is rarer and cannot be cured
• SCLC is exclusively for smokers
• SCLC is extremely chemoradiotherapy sensitive
• NSCLC is curable in stages 1,2,3
• Commonly metastasises to adrenal glands
• Cisplatin + pemetrexed – adenocarcinoma
• Cisplatin + gemcitabine – squamous cell carcinoma

Oesophageal cancer
Pathophysiology
• Adenocarcinoma – lower 1/3
• Squamous cell carcinoma – upper 2/3
Risk factors
• Adenocarcinoma
o Barrett’s oesophagus
o GERD
• Squamous cell carcinoma
o Smoking
o Alcohol
Symptoms
 • Progressive dysphagia
• Odynophagia
• Dyspepsia
• Hoarseness
• Cachexia
• Horner’s syndrome
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
o Upper endoscopy
▪ Biopsy + brush cytology
o Barium radiography
o PET-CT
Differential diagnosis
•
Staging
• Endoscopic US – to check depth of invasion into muscular layers
• PET-CT
Treatment
• Stage I,II
o Surgery (5cm of surrounding healthy tissue needs to be removed)
o + Adjuvant chemotherapy (5FU + leucovorin + oxaliplatin)
• Stage III
o Cisplatin + 5FU/paclitaxel + carboplatin
o + Radiation
• Stage IV
o 5FU + leucovorin + oxaliplatin
• If HER2 +ve
o 5FU + leucovorin + oxaliplatin + trastuzumab
• If HER2 -ve, PDL > 1%:
o 5FU + leucovorin + oxaliplatin + nivolumab
Prognosis
•
Special notes
• Surgery is easier for adenocarcinoma
• 5FU + leucovorin + oxaliplatin (IV)
• Capecitabine + oxaliplatin (oral)
• SCC responds better to radiotherapy than adenocarcinoma

Gastric cancer
Pathophysiology
• Mostly adenocarcinoma at the gastroesophageal junction
o Intestinal type – more common
o Diffuse type
Risk factors
• Smoking
• Alcohol
• Smoked/salted/pickled foods
• H pylori infection
• Obesity
• Pernicious anaemia
• Blood type A
Symptoms
• Cachexia
• Abdominal pain
• N&V
• Dyspepsia
• Haematemesis
• Melena
• Virchow’s node – metastasis
• Sister Mary Joseph nodule – metastasis
• Paraneoplastic syndrome
o Acanthosis nigricans
o Leser-Trélat sign
 o Dementia
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
Differential diagnosis
•
Staging
• Endoscopic US – to check depth of invasion into muscular layers
•
Treatment
• Stage I
o Partial/total gastrectomy (5cm of healthy tissue needs to be removed) + D2 lymph
node dissection
o + Adjuvant chemotherapy
• Stage II,III
o Neo adjuvant chemotherapy (5FU + leucovorin + oxaliplatin + docetaxel)
o + Partial/total gastrectomy (5cm of healthy tissue needs to be removed) + D2 lymph
node dissection
o + Adjuvant chemotherapy (5FU + leucovorin + oxaliplatin + docetaxel)
• Stage IV
o Chemotherapy

▪ If HER2 +ve:
• Trastuzumab + 5FU + leucovorin + oxaliplatin (IV)
• OR Trastuzumab + capecitabine + oxaliplatin (oral)
▪ If HER2 -ve & PDL >1%:
• Nivolumab + 5FU + leucovorin + oxaliplatin (IV)
• OR Nivolumab + capecitabine + oxaliplatin (oral)
• Side effects:
• Complications:
Prognosis
• 5-year survival = 30%-45%
Special notes
• Less common since smoked & salted foods are no longer used for preservation
• Intestinal gastric cancer is more common and has a better prognosis
• Stage II, III treatment is because surgery is toxic + recovery is long & pts are not fit enough to
receive adjuvant chemo so it is given as neo adjuvant
• Most commonly pyloric antrum

Colorectal cancer
Pathophysiology
• Mostly adenocarcinoma
Risk factors
• Elderly male
• Low fibre, high red meat diet
• Obesity
• IBD
• Alcohol
• Smoking
• Familial adenomatous polyposis
• Hereditary non-polyposis colorectal cancer
Symptoms
• Change in stools
• Haematochezia – rectal
• Melena – colon
• Iron deficiency anaemia
• Bowel obstruction – left-sided colon cancer
• Tenesmus
Diagnosis
• Medical hx
• Physical exam
• Bloods
o CEA
o CA19-9
o Faecal occult blood
• Imaging
 o Colonoscopy
o PET-CT
Differential diagnosis
•
Staging
• Endoscopic US – to check depth of invasion into muscular layers
• Duke’s staging
Treatment
• Colon
o Stage I
▪ Surgery (5cm of healthy tissue needs to be removed + lymph nodes)
▪ + Observation
o Stage II, III
▪ Surgery (5cm of healthy tissue needs to be removed + lymph nodes)
▪ +/- Adjuvant chemotherapy
• 5FU + leucovorin + oxaliplatin (IV)
• OR Capecitabine + oxaliplatin (oral)
o Stage IV
▪ Resectable
• Chemotherapy (for 3 months)
• + Observation
• + Radical surgery – metastectomy + primary tumour (after monitoring
& responds well)
▪ Unresectable – KRAS/NRAS/BRAF +ve
• 5FU + leucovorin + oxaliplatin + bevacizumab
• OR Capecitabine + oxaliplatin + bevacizumab
▪ Unresectable – KRAS/NRAS/BRAF -ve (wild type)
• 5FU + leucovorin + oxaliplatin + cetuximab (+ bevacizumab if disease
progresses)
• OR Capecitabine + oxaliplatin + cetuximab (+ bevacizumab if disease
progresses)
• Rectal
o Stage I

▪ Surgery (5cm of healthy tissue needs to be removed + lymph nodes)

 ▪ +/- Adjuvant chemotherapy
• 5FU + leucovorin + oxaliplatin (IV)
• OR Capecitabine + oxaliplatin (oral)
o Stage II

▪ Neoadjuvant chemotherapy
• Capecitabine OR 5FU
▪ + Radiotherapy
▪ + Surgery (5cm of healthy tissue needs to be removed + lymph nodes)
o Stage III

▪ Neoadjuvant chemotherapy – for 3 months

• 5FU + leucovorin + oxaliplatin (IV)
• OR Capecitabine + oxaliplatin (oral)
▪ + Neoadjuvant chemotherapy
• Capecitabine OR 5FU
▪ + Radiation therapy
▪ + Surgery (5cm of healthy tissue needs to be removed + lymph nodes)
o Stage IV

▪ Resectable
• Chemotherapy – for 3 months
• + Observation
• + Radical surgery – metastectomy + primary tumour (after monitoring
& responds well)
▪ Unresectable – KRAS/NRAS/BRAF +ve
• Bevacizumab + 5FU + leucovorin + oxaliplatin
• OR Bevacizumab + capecitabine + oxaliplatin
▪ Unresectable – KRAS/NRAS/BRAF -ve (wild type)
• Cetuximab + 5FU + leucovorin + oxaliplatin (+ bevacizumab if
disease progresses)
• OR Cetuximab + capecitabine + oxaliplatin (+ bevacizumab if disease
progresses)
• Side effects:
• Complications:
Prognosis
• Epithelial involvement – 5-year survival = 98%
 • Muscular involvement – 5-year survival = 90%
Special notes
th
• 4 most common cancer worldwide
• Radiation therapy is used a lot in rectal cancer; never used in colon cancer
• Need to check microsatellite instability (MSI). 5% MSI high – only immunotherapy needed
(Pembrolizumab)

Pancreatic cancer
Pathophysiology
• Mostly adenocarcinoma
Risk factors
• Smoking
• Alcohol
• Obesity
• DM II
o Metformin decreases the risk
Symptoms
• Obstructive jaundice
• Pale stools
• Dark urine
• Generalised itchiness
• Palpable epigastric mass
• New onset DM
• Worsening DM
• Pain
• Indigestion
Diagnosis
• Medical hx
• Physical exam
• Bloods
o CA19-9
• Imaging
o CT/MRI
• Biopsy
 o Adenocarcinoma
Differential diagnosis
• Cholangiocarcinoma
Staging
• Endoscopic US – to check depth of invasion into muscular layers
•
Treatment
• Stage I, II
o Surgery (Whipple’s - 5cm of healthy tissue needs to be removed) + pancreatic
supplements
o + 5FU + leucovorin + irinotecan + oxaliplatin
• Stage III
o 5FU + leucovorin + irinotecan + oxaliplatin
o + Surgery (Whipple’s - 5cm of healthy tissue needs to be removed) + pancreatic
supplements
• Stage IV
o 5FU + leucovorin + irinotecan + oxaliplatin
o OR Gemcitabine if FOLFIRINOX is intolerable
• Side effects:
• Complications:
Prognosis
• Poor prognosis: early disease 5-year survival = 25%; advanced disease survival = 6 months
Special notes
• Only 20% are operable; 80% have unresectable metastasis
• Many patients die during surgery

Hepatocellular carcinoma
Pathophysiology
•
Risk factors
• Hepatitis C/B
• Alcoholic fatty liver disease
• Cirrhosis
• Haemochromatosis
Symptoms
• Hepatomegaly
• Pain
•
Diagnosis
• Medical hx
• Physical exam
• Bloods
o AFP
o PTT
o PT
• Imaging
o US
o CT/MRI
o Angiography
Differential diagnosis
•
Staging
• Endoscopic US – to check depth of invasion into muscular layers
• Okuda system
• Cancer of the Liver Italian Program system
• Barcelona Clinic Liver Cancer scoring system
• Child-Pugh scoring system
Treatment
• Surgery
o Liver resection
o Liver transplantation (used only when tumour is small)
o TAE/TACE – transcutaneous artery embolisation/transcutaneous artery chemo-
embolisation (used when liver cannot be resected)
• Immunotherapy (if pt doesn’t have varicose veins)
o Bevacizumab + atezolizumab
• Targeted drugs – when immunotherapy cannot be used
o Sorafenib
 o Sunitinib
• Side effects:
• Complications:
Prognosis
•
Special notes
• Liver & HCC are both radiosensitive; liver is MORE radiosensitive
• Chemotherapy has no effect on the liver, so is not used
• If immunotherapy is used on pts with varicose veins, they will bleed

Breast cancer
Pathophysiology
• Ductal carcinoma – most common
• Lobular carcinoma
• Oestrogen receptor +ve
• Progesterone receptor +ve
• HER2 +ve
• Triple -ve
Risk factors
• Increased age
• Prolonged oestrogen exposure
o Early menarche/late menopause (after 55YO)
o Nulliparity/late age at 1 pregnancy (> 30YO)
st

o OCP (> 4 years before 1 pregnancy)

st

o Infertility (&IVF)
• Family hx
• Mutations
o BRCA 1/2
o p53
• Klinefelter’s syndrome – men
• Ashkenazi Jewish
Symptoms
• Non-mobile lump in breast
 • Axilla lump
• Orange peel skin
• Nipple discharge
• Newly inverted nipple
• Deformed areola
• Lymphoedema
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
o Mammography – only detects ductal carcinoma
o US
• Core needle biopsy
Differential diagnosis
•
Staging
• CT chest
• Bone scintigraphy – for metastatic symptoms
Treatment
• < 2cm
o Conservative surgery (lumpectomy)
o + Radiotherapy (45-50 Gy)
o + Tamoxifen
• > 2cm
o Induction chemotherapy (doxorubicin + cyclophosphamide then docetaxel) +
surgery + adjuvant chemotherapy
• Luminal A (ER +ve, PR +ve, low Ki67)
o Stage I, II
▪ Surgery
▪ + Radiotherapy
▪ + Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase
inhibitors – postmenopausal) for 5 years
o Stage III
 ▪ Surgery
▪ + Radiotherapy
▪ + Adjuvant chemotherapy (doxorubicin + cyclophosphamide then docetaxel)
▪ + Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase
inhibitors – postmenopausal) for 5 years
o Stage IV

▪ Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase inhibitors

– postmenopausal)
• Luminal B (ER +ve, PR +ve, HER2 +ve) OR HER2 +ve only
o Stage I
▪ Surgery
▪ + Radiotherapy
▪ + Adjuvant chemotherapy
▪ + anti-HER2 (paclitaxel + trastuzumab)
▪ + Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase
inhibitors – postmenopausal) for 5 years
o Stage II, III

▪ Neoadjuvant chemotherapy (doxorubicin + cyclophosphamide then docetaxel

+ trastuzumab)
▪ + Surgery
▪ + Radiotherapy
▪ + Trastuzumab for 1 year
▪ + Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase
inhibitors – postmenopausal) for 5 years
o Stage IV

▪ Chemotherapy
▪ + Anti-HER2 (paclitaxel + trastuzumab)
o Endocrine therapy (GnRH + tamoxifen – premenopausal; aromatase inhibitors –
postmenopausal), then chemotherapy
o Endocrine therapy, then chemotherapy + anti-HER2
• Triple -ve
o Stage I, II, III
▪ Neoadjuvant chemotherapy (doxorubicin + cyclophosphamide then docetaxel)
▪ + Surgery
▪ + Radiotherapy
 o Stage IV, BRCA +ve

▪ Olaparib
o Stage IV, PDL >1%

▪ Pembrolizumab
▪ + Chemotherapy (doxorubicin + cyclophosphamide then docetaxel)
o Stage IV, -ve BRCA, -ve PDL

▪ Chemotherapy (doxorubicin + cyclophosphamide then docetaxel)

• Metastasis
o Endocrine therapy
• Follow up – physical exam, DEXA,
o Every 3-4 months in the first year
o Every 6 months
o Every 1 year
• Sentinel lymph node removal – to avoid lymphoedema
• Side effects: hot flushes,
• Complications: lymphoedema (when all regional lymph nodes are removed)
Prognosis
• Much worse in younger population
• HER2 +ve is the worst clinical outcome
• Luminal A > luminal B > HER2 overexpression > basal-like (triple -ve)
Special notes
• Most common solid tumour in the world – in men and women
• Ovarian ablation < 35YO decreases the risk by 60%
• Common metastasis sites: liver, lungs, bones, brain
• 60% express oestrogen receptor – better outcome
• Ki-67 shows how fast the cancer is replicating. > 20% = higher risk
• Chemotherapy + endocrine therapy must NEVER be used at the same time
• Tamoxifen increases endometrial hyperplasia,

Ovarian cancer
Pathophysiology
• Epithelial
o Serous
 o Mucinous
o Clear cell
Risk factors
• Elder women
• Prolonged oestrogen exposure
o Early menarche/late menopause (after 55YO)
o Nulliparity/late age at 1 pregnancy (> 30YO)
st

o Infertility (&IVF)
• Hereditary non-polyposis colorectal cancer
• PCOS
• Endometriosis
• Ashkenazi Jewish
Symptoms
• Abdominal enlargement
• Ascites
•
Diagnosis
• Medical hx
• Physical exam
• Bloods
o CA125
• Imaging
o Pelvic US
o Pelvic + abdominal MRI
o Chest CT – for metastasis
• Laparoscopic biopsy
• FNA of metastatic mass
Differential diagnosis
•
Staging
• FIGO
Treatment
• Stage I, II, III
 o Surgery
o + Adjuvant chemotherapy (carboplatin + paclitaxel)
• Stage IV, resectable
o Neoadjuvant chemotherapy (carboplatin + paclitaxel) + bevacizumab
o + Surgery
o + Adjuvant chemotherapy (carboplatin + paclitaxel) + bevacizumab
o + Bevacizumab for 1 year
• Stage IV, BRCA +ve
o Olaparib
o + Carboplatin + paclitaxel + bevacizumab
• Recurrent disease
o If recurrence occurred after 6 months (platinum-sensitive disease) – carboplatin
o If recurrence occurred before 6 months (platinum-resistant disease) –
o If recurrence occurred during treatment (platinum refractive disease) –
• Side effects:
• Complications:
Prognosis
• Epithelial ovarian cancer 5-year survival = 44%
• Mucinous & clear cell have the worst prognosis
Special notes
nd
• 2 most common gynaecological cancer
• Protective factors: multiparity, breastfeeding, tubal ligation, salpingo-oophorectomy, OCP
• Radiotherapy is NOT effective
• Most common metastatic site: liver

Endometrial cancer
Pathophysiology
• Endometrioid – most common
• Type 1
• Type 2
Risk factors
• Older women
• Obesity
 • DM
• Advanced liver disease
• PCOS
• Prolonged oestrogen exposure
o Early menarche/late menopause (after 55YO)
o Nulliparity/late age at 1 pregnancy (> 30YO)
st

o Infertility (&IVF)
Symptoms
• Bleeding after menopause
• Prolonged/heavy menses
• Profuse serosanguinous discharge
Diagnosis
• Medical hx
• Physical exam
o D&C
o Endometrial biopsy
• Bloods
o CA125
• Imaging
o Pelvic US
o Pelvic + abdominal MRI
o Chest CT – for metastasis
Differential diagnosis
•
Staging
• FIGO
Treatment
• Stage I, II
o Surgery
o + Chemoradiation therapy (cisplatin) – for high risk
o OR + Radiation therapy – for lower risk
o OR + Vaginal brachytherapy – for lowest risk
• Stage III
 o Chemoradiation therapy (cisplatin)
o + Vaginal brachytherapy
• Stage IV
o Chemotherapy (paclitaxel + carboplatin + bevacizumab) – if there’s no excessive
bleeding
o Palliative radiotherapy – to stop bleeding
• Stage IV, PDL > 1%
o Chemotherapy (paclitaxel + carboplatin + bevacizumab)
o + Pembrolizumab
• Distant metastasis
o Aromatase inhibitors
• Progesterone IUD – for early stages to protect fertility
• Side effects:
• Complications:
Prognosis
• Stage I 5-year survival = 81-91%; tumours > 2cm have the worst prognosis
Special notes
• Radiotherapy is effective
• Protective factors: smoking, physical activity, OCP

Cervical cancer
Pathophysiology
•
Risk factors
• Younger women
• Unsafe sexual practices
• HPV 16 & 18
• Early onset of coitus (< 18YO)
• Smoking
Symptoms
• Postcoital bleeding
• Dyspareunia
• Vaginal discharge
 • Heavy menses
• Bleeding between menses
Diagnosis
• Medical hx
• Physical exam
o Pap smear
o Cytology + biopsy
• Bloods
• Imaging
o Pelvic US
o Pelvic + abdominal MRI
o Chest CT – for metastasis
Differential diagnosis
•
Staging
• FIGO
Treatment
• Stage I, II
o Surgery
o + Chemoradiation therapy (cisplatin) – for high risk
o OR + Radiation therapy – for lower risk
o OR + Vaginal brachytherapy – for lowest risk
• Stage III
o Chemoradiation therapy (cisplatin)
o + Vaginal brachytherapy
• Stage IV
o Chemotherapy (paclitaxel + carboplatin + bevacizumab) – if there’s no excessive
bleeding
o Palliative radiotherapy – to stop bleeding
• Stage IV, PDL > 1%
o Chemotherapy (paclitaxel + carboplatin + bevacizumab)
o + Pembrolizumab
• Progesterone IUD – for early stages to protect fertility
 • Side effects:
• Complications:
Prognosis
•
Special notes
• Most common gynaecological cancer
• Radiotherapy is effective
• Penile circumcision reduces risk

Renal cell carcinoma

Pathophysiology
• Clear cell RCC – most common
• Papillary RCC – type 1 & type 2
• Chromophobe RCC
• Collecting duct RCC
Risk factors
• Smoking
• Hypertension
• Obesity
• Polycystic kidney disease
• CKD
o & Long-term dialysis
• Von Hippel-Lindau disease
Symptoms
• Incidental renal mass
• Haematuria
• Flank pain
• Flank mass
• Paraneoplastic syndrome
o Stauffer syndrome
Diagnosis
• Medical hx
• Physical exam
 • Bloods
o PT
o PTT
• Imaging
o Pelvis & abdomen CT
o Chest XR
o Bone scan – for elevated ALP, Ca or bone pain
2+

o Brain MRI – even if asymptomatic

Differential diagnosis
•
Staging
•
Treatment
• Stage I, II
o Surgical resection (partial nephrectomy) – for < 4cm
o Surgical resection (radical nephrectomy) – for > 4cm
o + Observation
• Stage III
o Surgery
o + Pembrolizumab for 1 year
• Stage IV
o Surgery
o Pembrolizumab
o Sunitinib
o PDGF inhibitor
o mTOR inhibitor
o PDL inhibitors
• Side effects:
• Complications:
Prognosis
• Collecting duct RCC has the worst prognosis
• Median survival for favourable prognosis is 20 months
Special notes
 • Adjuvant therapy has not been proven to be beneficial
• Chemotherapy has not been proved to be beneficial

Prostate cancer
Pathophysiology
• Adenocarcinoma
Risk factors
• Increased age
• BPH
• Family hx
• High red meat diet
Symptoms
• Urinary urgency
• Urinary frequency
• Incomplete emptying
• Nocturia
Diagnosis
• Medical hx
• Physical exam
o DRE
• Bloods
o PSA
• Imaging
o US
o Pelvic MRI
o Bone scintigraphy – to exclude bone disease
• Core biopsy
Differential diagnosis
•
Staging
•
Treatment
• Stage I, II
 o Active surveillance
o Surgery
o + Adjuvant androgen deprivation therapy (zoladex) for 2 years
• Stage III
o Radical radiotherapy
o + Adjuvant androgen deprivation therapy (zoladex) for 2 years
• Stage IV
o Androgen deprivation therapy (zoladex) – for limited disease
o Docetaxel – for progessive disease
o Cabazitaxel – for even more progression
o Palliative radiotherapy for symptomatic care
• Side effects: erectile dysfunction, menopause symptoms, loss of libido, gynaecomastia
• Complications: cystitis, proctitis, fatigue, impotence, incontinence
Prognosis
•
Special notes
• Protective factors: cruciferous vegetables, soy products, tomato products
• Common metastasis to bone

Testicular cancer
Pathophysiology
• Seminoma – most common
• Non-seminoma
Risk factors
• 20-35YO
• Cryptorchidism
• Klinefelter syndrome
• HIV
• Sarcoidosis
Symptoms
• Testicular nodule/swelling
• Testicular heaviness
• Hard testicle
Diagnosis
• Medical hx
• Physical exam
• Bloods
o bhCG – elevated in non-seminoma only
o AFP – elevated in non-seminoma only
o LDH
• Imaging
o Testicular US
o Chest XR
o Chest/abdomen/pelvis CT – if metastasis is suspected
• Radical inguinal orchiectomy – if oncomarkers are +ve
Differential diagnosis
• Epididymitis, orchitis, hydrocoele, lymphoma
Staging
•
Treatment
• Stage I
o Orchiectomy (+ lymph node dissection for non-seminoma)
o + Observation
o OR Chemotherapy (bleomycin + etoposide + cisplatin)
• Stage II, III
o Orchiectomy
o + Chemoradiation therapy – for seminoma
o OR Lymph node dissection – for non-seminoma
• Stage IV
o Chemotherapy (bleomycin + etoposide + cisplatin)
o + Surgery – if response is good
• Side effects:
• Complications: lymphoedema – non-seminoma treatment (lymph node dissection), pulmonary
fibrosis (bleomycin)
Prognosis
• Seminoma testicular carcinomas have a better prognosis
 • 5-year survival = > 95% in any stage
Special notes
• Seminomas are chemoradio-sensitive
• Non-seminomas are not radio-sensitive
• Malignant transformation of primordial germ cells

Rhabdomyosarcoma
Pathophysiology
• Originating from mesenchymal cells
• Embryonal – most common
• Alveolar
Risk factors
• Germline mutations – p53
• Congenital abnormalities
•
Symptoms
• Proptosis
• Nasal discharge
• Cranial nerve palsies
• Headache
• Urinary obstruction
• Paratesticular scrotal mass
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
o CT/MRI
o PET-CT – for staging
• Open biopsy
Differential diagnosis
•
Staging
 •
Treatment
• Resectable
o Afferent surgery
o + Radiation
• Unresectable
o Chemotherapy (doxorubicin + ifosfamide) – rarely works
o + Radiation
• Side effects:
• Complications:
Prognosis
•
Special notes
• Most sarcomas are chemo-resistant
• Children & adolescent – Ewing sarcoma
•

Osteosarcoma
Pathophysiology
•
Risk factors
• Trauma
Symptoms
• Bone pain
• Swelling
• Mass in metaphyseal area of bone – commonly femur/tibia
Diagnosis
• Medical hx
• Physical exam
• Bloods
• Imaging
o Xray
▪ “Sunburst” appearance
 ▪ “Onion skin” appearance
▪ “Motheaten” appearance
o CT/MRI – for staging
Differential diagnosis
•
Staging
•
Treatment
• Resectable
o Limb sparing resection
• Doxorubicin + ifosfamide
• Side effects:
• Complications:
Prognosis
•
Special notes
• Most sarcomas are chemo-resistant
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•

Cerebral palsy
Pathophysiology
•
Risk factors
•
Symptoms
•
Diagnosis
•
Differential diagnosis
•
Staging
•
Treatment
• Side effects:
• Complications:
Prognosis
•
Special notes
•